Inspection on 14/03/07 for Chaldon Rise

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chaldon Rise 06/11/07

Chaldon Rise 20/06/06

Chaldon Rise 09/01/06

Chaldon Rise 13/09/05

Chaldon Rise 15/11/04

Chaldon Rise 15/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Chaldon Rise Rockshaw Road Merstham Surrey RH1 3DE Lead Inspector Lesley Garrett Key Unannounced Inspection 14th March 2007 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaldon Rise Address Rockshaw Road Merstham Surrey RH1 3DE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01737 645171 01737 644590 chaldon@careunlimited.co.uk Care Unlimited Mrs Carmelita Paat Shamtally Post Vacant Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Learning registration, with number disability (10), Mental disorder, excluding of places learning disability or dementia (5) Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2006 Brief Description of the Service: Chaldon Rise is one of three homes owned by Care Unlimited, and is a country house, which stands in its own five-acre grounds that surround the home. The house is situated on the outskirts of Merstham village. The home is registered to offer nursing care for up to 34 older people with Dementia. The home can also care for up to 10 residents with learning disability and 5 with a mental disorder. Accommodation is arranged over three floors accessible by a lift. Bedrooms are mainly single with en-suite toilets and some have bathrooms. The home offers car-parking facilities for several vehicles. The prices of the rooms are from £630 - £834 per week. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over seven hours and started at 0940 finishing at 1630. Lesley Garrett, Lead Regulation Inspector for the service carried out the inspection and the deputy manager, providers, human resource and quality managers represented the establishment. A tour of the premises took place and the inspector met some service users and viewed their bedrooms. Verbal feedback from service users was limited as a result of their mental health needs. A pre-inspection questionnaire was used as information for the inspection and service user survey forms (comment cards) were sent to the service and were available for the purpose of writing this report. Policies and procedures were also sampled and the inspector also looked at the individual plans of care and staff employment folders. The inspector would like to thank the service users and staff at Chaldon Rise for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? At the site visit in June 2006 a total of fourteen requirements were made and these have all now been met. The home now reviews all care plans monthly and there is evidence that relatives or representatives are consulted about the care their relative receives. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 6 The policies and procedures relating to medications have been reviewed and updated and medication is ordered and received by service users at appropriate times in order to promote their well being. Senior managers at the home have now completed their safeguarding adults training to ensure the protection of service users and the contact details of the commission have been included on the complaints policy displayed in the home. A registered manager was appointed and registered with the commission but resigned after a very short period, therefore this process has begun again. The quality manager has now had the opportunity to review all policies and procedures within the home to ensure the welfare of the service users and staff regarding appropriate procedures. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users that move into the home have their needs assessed by someone competent to do so and are then assured that their needs would be met. The home has no intermediate care beds. EVIDENCE: The deputy manager stated that all admissions to the home have a preadmission assessment. Either herself or the provider would carry these out. Evidence of these assessments was seen in the individual folders and care plans are then generated from the assessment. The home does not provide intermediate care beds. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. There was clear demonstration that medication was administered to service users in a safe way and privacy and dignity of the service users are maintained. EVIDENCE: The inspector sampled some individual service user folders and found them to contain a good variety of care plans and risk assessments. These plans demonstrated that the staff had a good understanding of the service users needs and were clearly written. Since the last key inspection in June 2006 the home has consulted with all of the service users relatives or representatives and they are now consulted about their plans of care. We spoke with the proprietor and the deputy manager and recommended the content of the files be reduced by means of archiving the historical documents to ensure the plans are easier to read for both staff and the service users relative or representative. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 10 The deputy manager stated that the General Practitioner (G.P.) would visit whenever called and the surgery are a good support to the home. ‘Comment cards’ received from the G.P. indicated that there was good communication and staff had a clear understanding of the care needs of service users. The opticians and chiropodist also visit the home regularly to ensure the health care needs of service users are fully met. The deputy manager also stated that the home has access to a palliative care team should any service user require this. The medication procedures were also sampled and we found that the requirements made in July 2006 following a visit by the pharmacy inspector have all now been met. These included a review of the medication policies and procedures, which have now been completed and audits take place regularly as part of the quality monitoring systems. A thermometer has been purchased for the medication fridge and is in place and individual protocols are in place for all medication that is required occasionally. It was observed that medicine pots were on the top of the radiators for drying. This is not good practice for infection control purposes. The provider immediately spoke to the nurse responsible and the pots were removed and stored appropriately. The privacy and dignity of service users are maintained as we observed that the windows in each bedroom door remain covered with an opaque film therefore personal care can take place in privacy. The bedroom doors all have locks and those on the ground floor remain locked when service users are not in their rooms to ensure their security. Due to the needs of the service users it was not possible to seek their views of the locked door but the proprietor explained it was to prevent the service users wandering into each other’s bedrooms and disturbing them and this is documented in the care plans. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities take place and visitors are welcomed to the home to maintain contact with their family members. Service users are helped to exercise some choice over their lives and a balanced diet is provided and taken in appropriate surroundings. EVIDENCE: The home has an activities organiser, who works Monday to Saturday, and off Wednesdays, who encourages service users to participate in a variety of activities. We observed the programme of events that are planned for the month, which include group activities and one to ones. On the day of the site visit no activities were planned. The service users have access to religious services as the deputy manager stated that the vicar visits every other week and has communion service every other week. The Roman Catholic priest will visit when required but volunteers visit every week and the Methodist minister will also visit when requested. Visitors are welcomed to the home and the deputy manager stated there are no restrictions on visiting times. We had the opportunity of speaking with Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 12 some visitors on the day of the site visit that were positive in their comments about the home stating ‘the staff are very open and tell you what is going on in the home’. Another said ‘I can’t praise the staff highly enough’. It was observed that choice is limited for service users due to their frailty but relatives confirmed that they were consulted on their care plans and likes and dislikes. Those service users that were able to communicate made choices about their food and where they would like to sit in the lounge and dining room. The chef and assistant chef were in the kitchen and spoke with the inspector. They were preparing lasagne for lunch. The provider stated that there had been a visit from the environmental health department in July 2006 and recommendations from that visit have now been implemented. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and taken seriously and service users are protected from abuse. EVIDENCE: The deputy manager told us that the home has a complaints log and all verbal concerns are noted in this book. All other complaints are logged with the human resource manager. The home has had two complaints since the last site visit which have been resolved within the timescales set out in the home’s complaints policy displayed in reception. The safeguarding adults policy was observed and is in line with the local authorities procedures. The deputy manager stated that the home has had one referral under these procedures since the last site visit, which has now been resolved. Staff have received training in the safeguarding procedures and the deputy manager stated that all senior managers have also completed their training. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, however refurbishment and re-decoration are needed in some areas to improve the presentation of the environment for service users. EVIDENCE: A tour of the building took place and we had the opportunity to discuss the environment with the providers and the quality manager. The home has a full time maintenance person and some of the bedrooms had been recently decorated. The bedrooms and communal areas need to be refurbished and the lighting improved. The three attic rooms were small and accessed by very narrow corridors. The bathroom on this floor could not be used as the toilet was broken and the bath had not worked for some time. On the day of the inspection the plumber did visit and the toilet was repaired. The proprietor and quality manager stated that the bath would be removed and a shower fitted to ensure bathing facilities Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 15 for the service users on this floor until the refurbishment of the home is undertaken. On the first floor there are two bedrooms with a connecting door. One of these doors had a security gate across it and the door was locked. The deputy manager explained access to the locked room was via the other bedroom due to the steps into the room. The inspector was advised that the service user accommodating this bedroom does not require the use of a hoist and a decision had been made by the home that the connecting door is locked to ensure the privacy and dignity of the service users. On the ground floor all of the bedroom doors are locked when the service users leave the room. The provider and quality manager stated this was to ensure that service users did not wander into each other’s rooms. The two communal lounges were well used with service users sitting in the armchairs. The deputy manager stated that the activity organiser does not work on a Wednesday and so the staff had put on music for the service users to listen to in both lounges. No requirements have been made concerning the environment as the provider told the inspector that plans are with the local authority to build an extension to the home and they hoped this work would begin soon once the plans had been approved. They stated that there would be no need to use the rooms in the attic when this work was completed. The deputy manager stated that the home has two laundry assistants who work in the laundry everyday. Infection control training is available to all staff including the laundry and domestic staff. The human resource manager stated that these staff are currently undertaking a distance-learning course with a local college. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and trained staff team supports the service users and the home has robust recruitment procedures. EVIDENCE: The deputy manager stated that the staff rota is flexible and caters for the assessed needs of the service users. We observed the rota and noted that numbers of staff varied from day to day depending on the activity that was planned for that day. The deputy manager stated that the level of staff never dropped below a minimum number, which was seven care staff in the morning and six for the afternoon. The national vocational qualification (NVQ) training continues at the home and the deputy manager stated that some carers had recently qualified and more were on the course. The human resource manager stated that staff, prior to starting their NVQ course, is registered on a recognised training programme. Some recruitment folders were sampled. At the site visit in June 2006 a requirement was made for any gaps in employment history to be explained and this has now been completed. The home has a training programme and we saw this. The human resource manager stated that the only training that is taking place and not evident on Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 17 the programme was distance-learning courses and this included the infection control training. All mandatory training is planned for the year and this includes safeguarding adults, manual handling and food hygiene. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is without a registered manager but it is run in the best interests of the service users. The financial interests of the service users are safeguarded and the health and safety of all service users are promoted and protected. EVIDENCE: The home’s manager was registered with the commission in December 2006 and he resigned his post in January 2007. The deputy manager has resumed the role of acting manager and the providers are in daily contact to provide additional support. The home also has the benefit of a quality control and human resource manager to ensure the smooth running of the home. The provider stated that interviews have now taken place for the recruitment of the new manager and Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 19 hopes they will be in post in the very near future once all pre-employment checks have been completed. The home has a quality manager who is responsible for the quality assurance systems in the home. He stated that the quality audit tool that he has developed would be in line with the commission’s new quality assessment. Due to the frailty of most of the service users it was difficult to seek their views but the provider stated that relatives and friend’s opinions are welcomed. The providers stated that no service user manages their own finances. During the tour of the building some health and safety issues were observed. Three oxygen cylinders were in one service users bedroom and only one was secured in a stand the other two were against a wall. The provider arranged for these to be immediately removed and stored in the appropriate place to safeguard the service user from harm. The bathroom on the first floor was found to have a chemical substance left unattended. This was also removed immediately and stored in a locked cupboard in keeping with the control of substances hazardous to health (COSHH) guidelines. The first floor sluice was very untidy and inappropriate items stored in there included a vacuum cleaner. Again the proprietor arranged for these items to be immediately removed and stored in the correct place. The proprietor stated that all members of staff responsible had been spoken with to ensure future good practice. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the individual folders used for personal plans of care be reduced and historical information stored appropriately so that the volume is reduced making the document user friendly. Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chaldon Rise DS0000013307.V333819.R02.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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